A Stop-gain Variant c.220C>T (p.(Gln74*)) in FLNB Segregates with Spondylocarpotarsal Synostosis Syndrome in a Consanguineous Family

Spondylocarpotarsal synostosis (SCT) syndrome is a very rare and severe form of skeletal dysplasia. The hallmark features of SCT are disproportionate short stature, scoliosis, fusion of carpal and tarsal bones, and clubfoot. Other common manifestations are cleft palate, conductive and sensorineural hearing loss, joint stiffness, and dental enamel hypoplasia. Homozygous variants in FLNB are known to cause SCT. This study was aimed to investigate the phenotypic and genetic basis of unique presentation of SCT syndrome segregating in a consanguineous Pakistani family. Three of the four affected siblings evaluated had severe short stature, short trunk, short neck, kyphoscoliosis, pectus carinatum, and winged scapula. The subjects had difficulty in walking and gait problems and complained of knee pain and backache. Roentgenographic examination of the eldest patient revealed gross anomalies in the axial skeleton including thoracolumbar and cervical fusion of ribs, severe kyphoscoliosis, thoracic and lumbar lordosis, coxa valga, fusion of certain carpals and tarsals, and clinodactyly. The patients had normal faces and lacked other typical features of SCT like cleft palate, conductive and sensorineural hearing loss, joint stiffness, and dental enamel hypoplasia. Whole exome sequencing (WES) of two affected siblings led to the discovery of a rare stop-gain variant c.220C>T (p.(Gln74*)) in exon 1 of the FLNB gene. The variant was homozygous and segregated with the malformation in this family. This study reports extensive phenotypic variability in SCT and expands the mutation spectrum of FLNB.

Diagnosis and epidemiology of winged scapula in breast cancer patients: A systematic review and meta-analysis

BACKGROUND

Winged scapula (WS) is a critical complication of axillary surgery in patients treated for breast cancer, and is associated with pain, impairment of the upper extremity's function and poor performance in daily activities.

SOURCES OF DATA

A systematic review and meta-analysis were performed following the PRISMA guidelines. Two independent reviewers searched PubMed, Embase and Virtual Health Library databases from January 1, 2000 to December 1, 2020. Clinical studies evaluating the diagnosis and epidemiology of WS among breast cancer surgery (BCS) patients were included.

AREAS OF AGREEMENT

The diagnosis of WS relies almost entirely on physical assessment. Studies have suggested a high variability in the report of the incidence of WS given the subjectivity of its diagnosis, and the different criteria used during clinical assessment.

AREAS OF CONTROVERSY

The diagnosis of WS in BCS patients remains a challenge given the lack of standardized diagnostic protocols. Physical examination cannot rely on one manoeuvre only, as it may overlook patients with subtle injuries or overweight and contributing to the underreporting of its incidence.

GROWING POINTS

BCS patients undergoing axillary lymph node dissection experience a significantly higher incidence of WS than those undergoing sentinel lymph node dissection. The global incidence of WS after BCS is 16.79%. Additionally, the anterior flexion test and the push-up test are the most commonly performed diagnostic manoeuvers.

AREAS TIMELY FOR DEVELOPING RESEARCH

Further studies should aim for objective diagnostic tests, especially when the condition is not evident.

Current concepts review: peripheral neuropathies of the shoulder in the young athlete

Peripheral neuropathies of the shoulder and upper extremity are uncommon injuries that may affect the young athletic population. When present, they can result in significant pain and functional impairment. The cause of peripheral neuropathy in young athletes may be an acute, traumatic injury such as a shoulder dislocation or a direct blow to the shoulder girdle. Alternatively, repetitive overuse with resultant compression or traction of a nerve over time may also result in neuropathy; overhead athletes and throwers may be particularly susceptible to this mechanism of nerve injury. Regardless of etiology, young athletes typically present with activity-related pain, paresthesias, and dysfunction of the affected upper extremity. In addition to physical examination, diagnostic studies such as radiographs and magnetic resonance imaging (MRI) are commonly performed as part of an initial evaluation and electrodiagnostic studies may be used to confirm the diagnosis of peripheral neuropathy. Electrodiagnostic studies may consist of electromyography, which evaluates the electrical activity produced by skeletal muscles, and/or a nerve conduction study, which evaluates a nerve's ability to transmit an electrical signal. Although data are not robust, clinical outcomes for young patients with activity-related peripheral neuropathies of the shoulder are generally good, with most young athletes reporting both symptomatic and functional improvement after treatment.

Winged Scapula: A Comprehensive Review of Surgical Treatment

Winged scapula is caused by paralysis of the serratus anterior or trapezius muscles due to damage to the long thoracic or accessory nerves, resulting in loss of strength and range of motion of the shoulder. Because this nerve damage can happen in a variety of ways, initial diagnosis may be overlooked. This paper discusses the anatomical structures involved in several variations of winged scapula, the pathogenesis of winged scapula, and several historical and contemporary surgical procedures used to treat this condition. Additionally, this review builds upon the conclusions of several studies in order to suggest areas for continued research regarding the treatment of winged scapula.

Intercostal Nerve to Long Thoracic Nerve Transfer for the Treatment of Winged Scapula: A Cadaveric Feasibility Study

There are very few surgical options available for treating a patient with winged scapula caused by a long thoracic nerve (LTN) injury. Therefore, we devised a novel technique based on a cadaveric dissection whereby regional intercostal nerves (ICN) were harvested and transposed to the adjacent LTN in 10 embalmed cadavers (20 sides). The LTN was identified along the lateral border of the serratus anterior and ICNs were identified at the mid-axillary line inferior to the lower edge of the pectoralis major muscle. Along the mid-clavicular line, each ICN was transected and transposed to the adjacent LTN. The length and diameter of each ICN available for mobilization to the LTN were measured. All measurements were made with microcalipers. Within the operative site, the mean proximal and distal diameters of the LTN were 1.6 and 1.1 mm, respectively. The adjacent ICN had a mean diameter of 1.3 mm. On all sides, the ICN branches were easily transposed to the adjacent LTN without any tension. Anastomosis to the LTN was performed to the third through sixth ICN provided each intercostal was preserved and mobilized anteriorly at least as far as the midclavicular line. The end to end size match between donor and LTN was appropriate on all sides. We found that it is feasible to harvest adjacent ICNs and move these to the adjacent LTN. Such a procedure, after being confirmed in patients, might offer a new technique for restoring protraction following an LTN injury.

Isolated serratus palsy etiology influences its long-term outcome

HYPOTHESIS AND BACKGROUND

The cause of isolated serratus palsy is multifactorial, but evaluation of the mechanism of the injury indicates that the lesion to the long thoracic nerve is mechanical in origin in most cases. What is unknown, however, is how etiology influences its long-term outcome. We believed that overuse injuries may recover sooner and better than acute traumatic, infectious, or inflammatory injuries.

METHODS

We determined the presumed etiology of isolated serratus palsy in 92 patients treated by brace or observation only and compared it with its long-term outcome after a mean follow-up of 18.1 years (range, 2.1-26.9) by measuring pain, range of motion, and winging of the scapula.

RESULTS

Trauma preceded 22 (24%) of the cases, exertion 37 (40%), infection 14 (15%), and surgery/anesthesia 10 (11%). In 9 (10%) cases, no etiologic factor was evident. Serratus palsy preceded by infection recovered better than did cases with no infection, and those with palsy preceded by surgery/anesthesia had a poorer outcome than did those with no surgery (axilla, chest, or any other areas) or anesthesia. Those palsies caused by acute trauma or acute or chronic overuse/exertion had the same recovery course.

DISCUSSION AND CONCLUSION

Etiology of isolated serratus palsy influenced long-term outcome less than we had expected. It seems, however, that palsies caused by infection recover better and those caused by surgery wherever in the body recover most poorly.

Winged scapula caused by rhomboid paralysis: a case report

Scapular winging secondary to dorsal scapular nerve (DSN) damage is an underestimated condition. It is often caused by entrapment of the nerve due to a hypertrophic middle scalene muscle, or by stretching of the DSN during traumatic movements. The condition has also been attributed to myofascial pain syndrome of the rhomboids with entrapment of the DSN. The non-specific symptomatology reported by patients is often incorrectly diagnosed, and this can result in a high level of disability of the upper limb. A clinical case of misdiagnosed dorsal scapula entrapment is presented. Satisfactory shoulder function recovery, pain relief and reduction of disability were obtained after correct diagnosis of the condition and a comprehensive rehabilitation approach.

Reproducibility of isometric shoulder protraction and retraction strength measurements in normal subjects and individuals with winged scapula

BACKGROUND

The strength of the shoulder protractors and retractors may be compromised in individuals with winged scapula (IwWS). However, no standard approach to measuring the strength of these muscles has been described. The aim of this study was to study the intra-rater and inter-rater reproducibility of a fixed-base isometric dynamometer and to describe cutoff scores for clinically meaningful change for protraction and retraction isometric strength.

METHOD

Twice during a week, 20 normal subjects and 20 IwWS were tested by 2 independent raters.

RESULTS

IwWS were significantly weaker (P < .001) than control subjects in their protraction and retraction isometric strength. Excellent intra-rater and inter-rater correlations were obtained in most combinations, leading to low cutoff scores for meaningful change expressed in terms of the smallest real difference.

CONCLUSION

When it is properly used, the technique described in this paper is recommended as an effective clinical tool for the quantitative assessment of protraction and retraction isometric strength, both for status determination and for monitoring of change in IwWS during and after rehabilitation.

Polyester tape scapulopexy for chronic upper extremity brachial plexus injury

PURPOSE

To report the results of scapular stabilization for winging in patients with chronic upper brachial plexus injury.

METHODS

Eight patients, mean age 36 years, who had a winged scapula after successful restoration of major shoulder function by nerve transfer underwent scapular stabilization to the ribcage using polyester tape. The follow-up period ranged from 24 to 40 months (mean, 38 mo). Data collection included radiographic analysis, active range of motion measurement, University of California Los Angeles shoulder score, and visual analog scale pain score.

RESULTS

All patients had clinical improvement with resolution of scapular winging. Five patients had no winging and 3 had mild winging after the surgery. Mean active forward flexion increased from 101° preoperatively to 127° postoperatively. Mean active shoulder abduction increased from 91° preoperatively to 121° postoperatively. Mean University of California Los Angeles shoulder score improved from 17 to 27 and mean visual analog scale pain score improved from 6.1 to 0.7. In addition, mean lateral deviated angle increased from 4° from neutral preoperatively to 9° at the last follow-up. All patients reported satisfaction with postoperative appearance.

CONCLUSIONS

Outcomes of polyester tape scapulopexy in the short to intermediate term were favorable in terms of improved appearance, upper extremity function, and pain reduction in patients with winged scapula resulting from chronic upper brachial plexus injury, and with successful restoration of shoulder motion by previous nerve transfers.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Incidence and risk factors for winged scapula after surgical treatment for breast cancer

AIMS AND OBJECTIVES

To evaluate the incidence of winged scapula following surgical breast cancer treatment, determine its evolution over time and correlate factors that might influence this incidence.

BACKGROUND

Winged scapula is a complication that may occur as a result of exposing the long thoracic nerve during axillary lymphadenectomy for the treatment for breast cancer. There is no consensus in the literature about the incidence of this complication after surgical treatment for breast cancer, and complication rates range from 1·5-74%.

DESIGN

This is a prospective cohort study.

METHODS

A prospective cohort study was conducted including 57 patients with breast cancer who underwent surgical treatment. Each patient was assessed before and after the surgery, by means of Hoppenfeld manoeuvre. The incidence rate of winged scapula was calculated at four different times.

RESULTS

At the preoperative assessment, none of the patients presented with winged scapula, while 16 patients (28·1%) were shown to have this complication after the procedure. The incidence of winged scapula decreased over time. Factors associated with winged scapula were as follows: patients younger than 50 years, clinical stage I and II and no neoadjuvant chemotherapy. Other factors that were evaluated, such as type of surgery, number of lymph nodes compromised and removed, as well as body mass index, were not associated with the risk of winged scapula.

CONCLUSIONS

This study demonstrated that the incidence of winged scapula is low and decreased over time. Furthermore, a greater incidence of winged scapula was noted in young women at an initial stage of the disease who had not been treated with neoadjuvant chemotherapy.

RELEVANCE TO CLINICAL PRACTICE

The result of this work may have great impact, for demonstrating what risk factors are significantly associated with winged scapula after surgical treatment for breast cancer.

Fixation of winged scapula in facioscapulohumeral muscular dystrophy

OBJECTIVE

To verify if stabilizing the scapulothoracic joint without arthrodesis could lead to functional improvement of shoulder range of motion and clinical improvement of winged scapula, we incorporated four additional patients into our previous analysis to determine if the results obtained were long lasting, and to compare this fixation with the other techniques described in the literature, balancing the benefits with the complications.

DESIGN

A retrospective study.

PARTICIPANTS

Thirteen patients with bilateral winged scapula affected by facioscapulohumeral muscular dystrophy. Nine of these patients had been analyzed in our previous study.

METHODS

Patients were operated on by bilateral fixing of the scapula to the rib cage using metal wires without arthrodesis (scapulopexy).

RESULTS

All patients experienced improvement in active range of motion of the shoulder and all of them had clinical improvement with complete resolution of the winged scapula. In all twenty-six surgical interventions of scapulopexy, a stable and long-lasting fixation of the scapula to the rib cage was achieved. The complications strictly associated to the surgical technique encountered were one pneumothorax, which was resolved spontaneously, and one wire breakage without trauma. Average follow-up was 10 years (range, 3 to 18 years).

CONCLUSION

The scapulopexy used in this extended series of patients consisted of repositioning the scapula and fixing it to four ribs by using metal wires without performing arthrodesis. This technique has a low rate of complications, is reproducible, safe and effective, resulting in clinical and functional improvement.